(TRICARE) NEW FORMULARY RULE

Forwarded by BGen R. Clements, USAF (Ret)

In accordance with the requirement established in “Section 701, Pharmacy Benefits Program” of the FY 2000 National Defense Authorization Act, TRICARE has published a final rule, to become effective May 3, 2004.

This is the process for determining the formulary status for prescription drugs into one of three cost-share tiers, based upon their relative clinical and cost effectiveness, while also providing beneficiaries with continued access to the medications they need.

Once the new structure is fully implemented, prescription drugs on the current Military Health System (MHS) formulary will be categorized as generic, formulary (brand name), or non-formulary. Prescription drugs will be evaluated based on their relative clinical and cost effectiveness when compared with other drugs in the same therapeutic class.

The DOD Pharmacy and Therapeutics Committee, comprised of physicians and pharmacists, will guide this process - receiving input from a Beneficiary Advisory Panel representing the general interests of all DOD beneficiaries

Officials said the Uniform Formulary final rule does not change the TRICARE prescription drug benefit. The benefit includes the U.S. Food and Drug Administration approved drugs and medicines that by U.S. law require a physician's or other authorized provider's prescription. It does not include prescription drugs that are used in medical treatments or procedures that are expressly excluded from the TRICARE benefit by statute or regulation.

The official source will publish a list of prescription drugs categorized as non-formulary when final determinations are made.

“The military treatment facility (MTF) remains the best value for all users of the TRICARE pharmacy program,” said Col. William Davies, director, DOD Pharmacy Programs. “By having prescriptions filled at the MTF, TRICARE beneficiaries eliminate their out-of-pocket costs.”

Future prescriptions filled by the TRICARE Mail Order Pharmacy, or a retail network pharmacy will cost $3 for up to a 90-day supply of a generic medication, $9 for up to a 90-day supply of a brand-name formulary medication, and $22 for up to a 90-day supply of a non-formulary medication.

Beneficiaries choosing to fill prescriptions using a non-network pharmacy will pay either $9 or 20% of the total cost of the prescription, whichever amount is greater, for both generic and brand-name formulary medications; and $22 or 20% whichever amount is greater, for up to a 30-day supply of non-formulary medications. Applicable deductibles for non-network pharmacy use must first be met.

Up-to-date information on the TRICARE Pharmacy Program will be available on the TRICARE Web site http://www.tricare.osd.mil/pharmacy. TMA will announce the implementation schedule as the information becomes available.